Shared Vision and Purpose from the Top Drive SDOH Initiatives

The road to better health outcomes requires trust: trust between patient and provider, provider and staff, and staff and management. To succeed, everyone involved must be aligned toward the end goal.

The same can be said for social determinants of health (SDOH) initiatives. Trust to share, safely store, and use personal information related to a patient’s health requires full buy-in from all parties, especially when dealing with sometimes sensitive information about a person’s life.

AHIMA recently spoke with Tara Montgomery, founder and principal of Brooklyn, NY-based Civic Health Partners, a consulting and coaching firm, on the topic of establishing a common mindset on SDOH initiatives, building trust from those involved, and the critical role of the C-suite in getting programs off the ground.

AHIMA: When we are discussing building trust for SDOH initiatives, where do you see the health information (HI) professional fitting in?

Montgomery: Authentic trust is really integrated within a whole ecosystem. It's a culture. So when you’re building trust for SDOH initiatives, it doesn't matter if you're the data input person who's maybe thousands of miles away, or if you're the data analyst, or the clinician, or the information technology leader. All of you need to share values around trust and earn the trust of patients and community members.

A meaningful, cohesive culture of trust rooted in shared values leads to better outcomes on multiple levels. And in the case of SDOH, a culture of trust means better outcomes in terms of how data is used responsibly and meaningfully and what happens later because of it.

AHIMA: How do you generate that buy-in from everyone in the organization?

Montgomery: Buy-in begins with a shared vision and shared purpose from the top. Those things propagate throughout an organization. And when you have shared purpose, there's a lot more acceptance of how hard it feels to get where you're going to go together. You trust that you all have your eye on the same end goal.

At the same time, when you’re dealing with very sensitive data around health, people are going to have a lot of questions. There might even be pushback. Leaders need to create the conditions for psychological safety so that team members have permission to be honest. They need to have a space to give and receive feedback safely and without blame. Everyone in the room understands that they are part of a learning process. So there's forgiveness, if you like, in that regard. And when leaders are curious and not defensive, they can handle pushback by participating in meaningful conversations that might eventually lead to improvement. This is about change leadership as much as trust-building.

There is also the work of trusting yourself and reflecting on your own trustworthiness by asking yourself questions like: Am I competent to be doing this work? Am I competent to communicate about this work? Do I know how I react in difficult conversations? All the work you do on self-development and growing your emotional intelligence really ties into trusting yourself. After that, there comes trust in others. I think it's hard for many of us to give that gift of trust. So it's healthy for any organization to start with that kind of reflection … and then down the road, it really helps when you have a challenging project that requires broad trust.

AHIMA: How does an HI professional build that trust in themselves and then go to their organization and say they are confident in their abilities and ready to be part of the discussion?

Montgomery: The first ingredient of trust that they will need to bring is expertise (that is, professional competence). Then they will need to offer transparency (that is, communicate honesty). And they will need to have a positive motive in the conversation (to serve a common purpose, not a self-serving one).

Anybody working on SDOH initiatives, whether you're in information leadership or any other domain, is likely to be involved because you have the right qualifications and essential skills to contribute to solutions. So you should trust that you are entitled to contribute to the solution. That doesn’t mean you need to have the whole answer — because nobody does.

AHIMA: With that in mind, what is someone at a C-suite level to do when the organization looks to them for answers on an issue like social determinants of health and they just don’t have the answers or path forward?

Montgomery: That's what leading in a complex world looks like. So even the senior leaders have to be humble. They don't know how to solve big problems alone. Their job is to set the vision, provide the resources and the safe environment for people to collaborate, and bring their own expertise … with empathy and a shared vision. It’s not being afraid to say you don't have all the answers.

Today, the best leaders in any kind of organization are humble. It's no longer useful to have that authority figure persona. It's about leading with people and where your positional power might allow you to set a vision and guide and steer a roadmap.

Humble leadership is about supporting people to get things done and to look for collaborations with people that traditionally weren't in the room. So that could be mid-level people. It could be people from departments that were never included. It could be bringing people in at the beginning of the process and not just adding them as an afterthought.

It's also about including citizens and stakeholders from outside of your typical organization. That's about distributing power, even giving away power. It's about no longer controlling the process but trusting that the process will be better because of it.

The leaders I work with are learning that their superpower is to give breathing room to everybody else to collaborate, to solve challenging, complex problems because as we all know, our world is turbulent, uncertain, ambiguous. There’s constantly something new. And in that world, you always must lead by listening.

AHIMA: How do you build trust with patients, given some social determinants of health information is difficult to disclose?

Montgomery: It is a privilege to be in that conversation with a human who is very vulnerable in that moment, no matter how high status they are in the world or not.

Building trust starts today. Doctors are not authority figures in the way they used to be. They are people with the skills and the listening skills to help you solve a problem and explore all the different facets of the problem, which could include social, clinical, and genetic factors or other circumstances. And in this context, building trust first means making sure you're the right person to have that conversation. Because research confirms that a lot of people do better when the doctor relates to them, looks like them, and comes from a community like them.

There are boundaries you have to think about in the context of every conversation. What's professional and what's useful? And to ask: Is my self-disclosure helpful to the other person or not? But that can begin a trusting relationship and that needs to be built over time. And in these conversations, trust is about keeping promises. It's about making people feel heard. It's about not judging them. It's not different than other good relationships in the world.

But time is a challenge for physicians. Time can often be the actual barrier to doing all the things they know and wish they could do. And there are structural barriers like what health plan someone is in or who will pay for what.

Physicians need to keep the ingredients of trust in mind: Are you putting their interests above your own? Are you going to make money out of this encounter or not? Do you have a conflict of interest in this conversation? A patient can tell if you have their interests at heart. Another thing is really to try and allow patients to ask questions. Help them get their questions answered.

In return, they will answer yours. So this is a reciprocal interaction. It's not transactional. But it takes patience. If you ask too much of somebody at first, that isn't going to work with most people. They might respond because you're an authority figure, but they're not going to respond because they trust you. It's relationship building.

And you can't do everything at the first encounter, the first interaction. I think that's the thing with medicine. So how do you build the rapport with that patient with the time that you have? Well, probably how do you get them to come back? You get them at that point in time. And I know some physicians feel like, well, I have them right there.

And there's no guarantee that if I set the next appointment, they will come. So I feel like I have to do everything in that first encounter. But if you ask too much, if you come on too strongly, if you ask too many personal questions after I just met you and you just met me, that's a hard barrier to overcome.

For more information on social determinants of health, visit Data for Better Health™.